MEDICAL IMAGING REQUISITIONTel. 416-756-6167
SEE BELOW FOR FAX NUMBERSPREFERRED SITE: q General q Branson
Patient’s Name:
HC#: Version: DOB: Sex: M F
Tel#: Physician’s Billing Number:
Physician’s Name Printed: Signature: Tel:
q I understand that the Radiologist may require to schedule additional examinations related to the current investigation on my behalf. Initial here:
Clinical Information/Indication for Test:
nygh.on.ca
RadiologistsDr. E. LaMere, Chief Dr. P. Causer Dr. L. Grinblat Dr. B. O’HayonDr. K. Mak, Branson Site Director Dr. K. Cranstoun Dr. N. Isaac Dr. D. PhamDr. S. Armstrong Dr. H. Deif Dr. I. Jacobs Dr. H.R. StonemanDr. A. Bass Dr. L. Friedman Dr. E. Lai Dr. J. WortsmanDr. M. Chang Dr. B. Ginzburg Dr. R. Margau Dr. T. YatesDr. G. Chow Dr. R. Goldberg Dr. C. MacAdam
BREAST IMAGING SERVICES AND BMDq Routine Screening (including OBSP/High Risk OBSP)q Diagnostic (Workup)q Breast Ultrasound q Right q Leftq Other:
Tel. 416-635-2550 Fax 416-635-2401 FLUOROSCOPYFax:416-756-6766q Barium Swallowq Upper GI Seriesq Small Bowel Follow-thru
q Barium Enemaq Other:
q Baselineq Low Riskq High RiskDate of last BMD:
BONE DENSITY (BMD)
X-RAYChest & Abdomen: Spine: Head & Neck:q Chest (2 Views) q Cervical q Skullq Ribs R L q Thoracic q Sinusesq Sternum q Lumbo-Sacral q Facial Bonesq SC Joints q Sacrum & Coccyx q Nasal Bonesq Abdomen Single View q S-I Joints q Mandibleq Abdomen (2 views) q Soft Tissue Neck
Upper Extremities: Lower Extremities: Skeletal Survey:q Shoulder R L q Pelvis q Arthriticq Clavicle R L q Hip R L q Metastaticq Scapula R L q Femur R L q Scoliosisq AC Joints R L q Knee R L q Bone Age Studyq Humerus R L q Ankle R Lq Elbow R L q Tibia & Fibula R Lq Forearm R L q Foot R Lq Wrist R L q Calcaneus R Lq Scaphoid R L q Toes R L No. 1 2 3 4 5q Hand R L q Finger R L No. 1 2 3 4 5 q Other:
ULTRASOUND Fax:416-756-6370q Abdomen Completeq Female Pelvic (Transabdominal)q Transvaginalq HysterosonogramObstetrical Date LNMPq IPS NT Dating (12 - 14 WKS) q Anatomic (18 - 20 WKS)q Medical IndicationVascular Dopplerq Carotidq Arterial Upper Extremity R L q Arterial Lower Extremity R Lq Venous Upper Extremity R Lq Venous Lower Extremity R L
q Limited Abdomen (GB, Liver, Renal, etc.)q Male Pelvicq TransrectalSmall Partsq Baby Brain q Neck/Face q Salivary Glands q Thyroidq Testicular q Other:MSKq Baby Hips R Lq Knee R Lq Shoulder R Lq Other:
See other side for site addresses, patient preparation instructions, contact info, for CT/Interventional, MRI, Cardio Resp and Pre-Operative Breast Localizations
NUCLEAR MEDICINE Tel. 416-756-6258 Fax 416-756-5995Bone Scan: q Whole Body q Specific Site q SPECTGallium Scan: q Whole Body q Specific Site q SPECTThyroid Scan: q Uptake & Scan q Scan q UptakeLiver: q RBC (Hemangioma) q Sulfur Colloid
q Renal Scan q Captopril Renal Scan q Lasix Renal Scan(?Hypertension) (?UPJ Obstruction)
q Brain Scan SPECT q Biliary Scan (HIDA)q Lung Scan (V/Q) q Meckelsq Gastric Emptying Scan q Salivary Scanq Parathyroid Scan q I-131 Whole Body Scan q Other:
IMPORTANT: Reports for relevant imaging studies performed outside North York General Hospital MUST accompany this requisition.
